=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689102022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANAYOCHUKWU J. ANYA MD FACS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2017
-----------------------------------------------------
Last Update Date | 08/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6100 HARRIS PKWY STE 380
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-759-9008
-----------------------------------------------------
Fax | 844-583-5414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6100 HARRIS PARKWAY 380
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-759-9008
-----------------------------------------------------
Fax | 844-583-5414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. KANAYOCHUKWU KANNY JACQUELYNE ANYA
-----------------------------------------------------
Credential | MD FACS
-----------------------------------------------------
Telephone | 817-759-9008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | N9800
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------